WELL; The Annual Appointment Loses Some Relevance

By TARA PARKER-POPE

Published: March 20, 2012

For nearly three generations, women have been taught that annual Pap smears, mammograms and visits with their doctor were essential to good health.

Now all that is changing. National guidelines are urging less frequent screening for breast and cervical cancer. The declining use of menopause hormones means that older women no longer need to check in with their doctors to obtain annual refills. Women are delaying childbirth, and some birth control methods are effective for five years, giving women even less incentive to schedule a regular appointment.

For many women who have been making annual gynecological visits since their teens, the advice that it's no longer necessary is unsettling.

''I worry this is the wrong message,'' said Miriam Richards, a 52-year-old nurse in Raleigh, N.C., who was treated for precancerous dysplasia as a result of an annual Pap smear. ''I think it's a bad road to go down because I feel like women, especially young girls, need to stay vigilant.''

But medical experts continue to preach that when it comes to cancer screening, more is not necessarily better. For years, women were advised to start mammography screening at 40; then, in 2009, the United States Preventive Services Task Force raised the recommended age to 50 - and specified every two years, rather than annually.

Last week, the task force and medical groups, including the American Cancer Society, recommended cervical cancer screening with the Pap smear no more than every three years, and said women should not begin screening until age 21. In the past, screening was recommended every one to two years, within a few years of becoming sexually active.

The concern is that more frequent cancer screening, whether of the breast or the cervix, leads to more false positive results - and unnecessary, intrusive and painful biopsies that lead to stress, discomfort and, in the case of cervical cancer screening, bleeding and future risks for women in pregnancy.

The changing landscape of cancer screening is certain to have an effect on women's health care, although nobody is certain what it will be. Women have long been the most frequent users of health care, particularly for pregnancy care and pediatric visits for their children. But even when pregnancy and pediatric care are removed from the equation, women are still 33 percent more likely to visit the doctor, according to the Centers for Disease Control and Prevention. The rate of doctor visits for annual exams and preventive services for women is double that of men.

And importantly, gynecologists often use the annual visit to bring up nonreproductive issues: smoking, weight gain, high blood pressure, depression.

''I understand the strong relationship that has been formed with a woman's doctors during what may be her annual visits,'' said Dr. Wanda Nicholson, a member of the preventive services task force and associate professor at University of North Carolina at Chapel Hill. ''But our recommendation addresses only cervical cancer screening. It's not meant to alter or change women's ability to access their clinicians to discuss other concerns.''

Dr. Susan Love says that while annual doctor visits may feel reassuring, there is no evidence that they yield better health outcomes.

''There is no data that yearly physicals do anything,'' said Dr. Love, a breast cancer researcher and prominent women's health advocate in Santa Monica, Calif.

''In the current health care system, you rarely have the same doctor forever. And so the relationship you build in the 15 minutes you have will be for naught when you actually get sick.''

Some women say the new guidelines will not dissuade them from regular doctor visits, and may in fact make them more willing to schedule appointments, knowing they are less likely to be subjected to a pelvic exam and a Pap smear.

A 33-year-old Atlanta mother of two, who asked that her name not be published, said her insurance pays for just one wellness visit a year, and she would like to switch to a general practitioner for her care, rather than use up the payment on a visit to a gynecologist.

''I need to talk about more than reproductive issues with my doctor,'' she said. ''I don't want to talk to my gynecologist about my foot pain, but at the general practitioner we talked about foot and knee pain, he checked my skin for suspect moles, did blood work and I got a tetanus booster. We talked about my dad having precancerous colon polyps removed. You feel like you can talk about more things with a G.P.''

Ms. Richards, the nurse in North Carolina, says she is unsure how the changes will affect women's relationships with their doctors.

''First the mammogram issue and now the Pap issue,'' she said. ''It's either going to make us more determined to get what we need, or we're going to have a more cavalier attitude. It's the young girls I worry about.''

This is a more complete version of the story than the one that appeared in print.